INTRODUCTION TO SOCIAL AND CULTURAL

ANTHROPOLOGY

MENTAL ILLNESS STIGMA IN PAKISTAN:

Are we driving our mentally disordered
crazy?

SYEDA RAMSHA RIZVI

MON/WED, 4TH Slot
ERP ID: 07006
INTRODUCTION 3

LITERATURE REVIEW 6

RESEARCH DATA, THEORY AND ANALYSIS 9

General Pakistani Community 10

Mentally Disordered Individuals 12

Psychiatrists 13

CONCLUSION 14

BIBLIOGRAPHY 14
 Introduction

Few years down the memory lane, when my knowledge and perception on mental

illness stigma in my community was still in its preliminary stages of construction, a

young man who lived in my neighborhood suffered from a mental disorder. He used to

stage sporadic but frequent episodes of loud screaming, crying and breaking things.

Our neighborhood did not make things easier for him. He was not even preferred to

stand beside during obligatory prayers in mosque. As a result of this discrimination, he

chose not to leave his home often and throw more tantrums. Neighbor’s rights are held

in high esteem in the religion that an overwhelming majority in my neighborhood

followed, but this young man’s ordeal was paid no heed to by us; until one day when we

heard that this man, barely in his twenties and yet to discover and cherish opportunities

and happiness and to know a world where he felt accepted, has died.

Mental illness stigma is the word for demonstrating discriminating and disgracing

demeanor of the kind my neighbor had to suffer towards individuals who suffer from

mental disorders. According to US National Library of Medicine, some of the more

common mental disorders are anxiety disorders, bipolar disorder, depression, mood

disorder and psychiatric disorder including schizophrenia. Societal views of those with

mental illness often include misperceptions about dangerousness and violence

(Feldman & Crandall, 2007).

Pakistan is a state rife with social, political, health and financial challenges, therefore

there are many more cases of individuals who suffer from at least one of the

aforementioned mental disorder. According to Karwan-e-Hayat, an institute for mental

health and a NGO based in Karachi, a whopping 15 million people in Pakistan suffer

from mental disorder. Moreover, WHO’s statistics on mental health in Pakistan states

that neuropsychiatric disorders in the country is 11.9% of the global burden of disease.

Given these facts, it becomes imperative to talk about the stigma that surrounds mental

disorders in Pakistan. Mental disordered individuals are known to get fewer

opportunities and limited access to resources through discriminatory practices of

employers. (Corrigon,2004;DHHS,1999;Wahl 1999). There are two broad reasons that

will help explain the reason I decided to conduct research on mental illness stigma in

Pakistan.

Firstly, perhaps the most alarming problem that arises from stigma around mental

illness is that it negatively influences the mental disorder. The community’s tendency to

stigmatize mental illness reflects on the mental disordered individual’s self-esteem and

confidence (Corrigon: 2004). This can be supported by a research done by Link and his

colleagues where a group of people who were diagnosed with mental disorder were

interviewed to ask about, among other things “their perception that others would

devalue or discriminate against someone who has a mental illness” (Link, Struening,

Neese-Todd, Asmussen & Phelan, 2001). A follow-up interview was conducted at six

months and twenty four months, and the results produced illustrated that the people

who perceived highest discrimination against mental illness were nine times more likely

to have low self-esteem. Thus stigma serves as a challenging impediment for recovery

against mental disorder and aggravates the mental disordered individual’s ordeal by

discouraging him/her to seek help. (Ayalon and Alvidrez, 2007).

Secondly, mental illness stigma varies across culture. Having already established that

mental disorder is influenced by its stigma, it becomes incumbent to know about the

attributes and intensity of the stigma as it varies across cultures. Culture refers to the

shared beliefs, values and norms of a racial or ethnic group (Abdullah, T., & Brown, T.

(2011)). As Abdullah argues that most researches wrongly assume that stigma in every

culture is homogenous. This is true even though this notion that stigma varies across

cultures is not new. Laungani argues back in 1989 in his research paper titled, “Cultural

influences on Mental Illness”. He writes that: “If the underlying assumptions concerning

mental illness commonly shared by one culture are not shared by another culture, nor is

any serious attempt made to under- stand them, one is unlikely to learn a great deal

about the problem of mental illness within that particular culture. Moreover, if such

factors are not taken into account, any comparative studies undertaken in other cultures

are more likely to create a collage of distorted pictures which may not only, impede our

understanding of the genesis of the problem, but may lead to potentially dangerous

conclusions being drawn”. Therefore, in the light of aforementioned assertions, I have

undertaken the task to research on mental illness stigma within the Pakistani culture.

The ethnographic methods that I employed in doing this research are interviewing the

general community about their perception on mentally disordered people, interviewing

mentally disordered people about whether they feel discriminated or devalued in the

community and lastly interviewing psychiatrists and academics about their views on the

mental illness stigma in Pakistan. All the subjects of my interview are from Pakistan.

The interviews conducted from the community were paper-based, not long (10

questions on average) and comprised of range of objective and subjective questions. I

ensured that my questions did not subtly or explicitly point towards a certain answer

choice. Also, I ensured that my interview subjects were anonymous because they might

not want to express stigma of mental illness in fear of expressing views that are publicly

disliked and frowned upon. With anonymity, it was ensured with considerable certainty

that the interview subjects express what they really believe without being feared to be

negatively judged. The interview results can be a subject to sample bias owing to limited

resources and impracticality to interview the entire population.

Literature Review

Mental illness stigma has been a topic subject to research by many academics who

have specialized in this area. Their research papers seek to explain stigma through an

array of factors including culture, the effect of stigma on the mental disordered individual

and proposed strategies to combat it. Some of these academic research included

assertions that supported or did not support my research. Before I illustrate and analyze

my research findings in connection to these academic sources, this section will talk

about those academic sources itself.

One of such academic source is co-written by Tahirah Abdullah and Tamara L. Brown

and was published in Clinical Psychology Review. The central idea of this research

paper revolves around the differences in stigma in various cultural groups in light of

quantitative and qualitative studies. The research paper also proposes that there is a

need to explore values and history of a culture in order to determine how it is going to

perceive stigma. Their analysis on mental stigma among Asians proved a number of
things. 1) Asians prefer traditional therapist over psychiatrists. 2) Asians believe that

mental Illness is a punishment from God or has some other supernatural reason behind

it. 3) Academic and occupational success are highly worthy in Asian culture and

therefore mental illness stigma in Asia is high because mental disordered individuals

find it hard to be able to be academically or occupationally successful. For example,

they pointed out that Asian cultural values are positively related to stigma.

The second academic source that abetted my research findings and its analysis is

written by Pittu Laungani, an Indian born psychologist, in 1989. Even though

contemporary researches have extensively researched and deduced the positive

relationship between mental illness stigma and culture, Laungani wrote about this and

also attempted to explain the differences between mental illness stigmas in British and

Indian culture as early as 1989. He pointed out five main assumptions/premises in both

of these cultures and he explains mental illness stigma on the basis of these. These five

factors are: materialism vs spiritualism, individualism vs communism, free will vs

determinism and cognitivism vs emotionalism. For example, Laungani points out that

since British society is more individualistic than it is collectivist, a mental disordered

person is seen to be at fault for his own disorder. On the contrary, a mental disordered

individual in a collectivist society such as India is seen to be someone not conforming to

the norms of society and therefore the mental disorderly as well as his/her family is

stigmatized. However, Laungani also points out that the doctrine of determinism

followed extensively by Indians through which the mental disorder will not be seen as a

fault of afflicted, but a part of his predestined destiny, engenders passive acceptance of

the mental disorderly in the society because of this.

Another academic paper that helped me collate the reasons for the existing stigma with

the analysis present in this paper is co-written by Feldman, D., & Crandall, C. The main

purpose of this article is to delve into finding those features and attributes of mental

illness that causes stigmatization. They concluded that the features of mental disorder

that causes stigmatization or induces people to maintain social distance are three

dimensional: personal responsibility for the illness, dangerousness, and rarity of the

illness. In addition to this conclusion, they also proposed strategies to combat stigma in

the light of the reasons for the stigma. For example, they propose that mental health

therapist should address the stigmatization that mental disorderly receive from the

society. Also, public education regarding this may also prove useful as people tend to

stigmatize mentally disordered even when they know little about the mental disorder.

The research papers mentioned before were all researched in the context of American,

British, Asian or Indian society. While Asian and Indian cultures are to an extent

congruent to Pakistani culture, Pakistan is a diverse country of its own and it was

imperative that I had a research paper on mental illness stigma in context of Pakistani

community. The research done by Wheeler on mental illness stigma in 1998 on

Pakistani community in UK proved to be particularly useful. Women who were

discharged from in-patient psychiatric care were interviewed. The research found out

that their hospitalization had caused them to lose respect from children and involvement

in decision making of the family. The paper then proposes that facilities that does not

introduces itself as “mental” health service should be more accessible. Also, home

based care is encouraged as it precludes stigmatization associated with hospitalization.

Even though all of the research papers above proved exceedingly useful in my analysis

of mental illness stigma in Pakistan, it was incumbent that an in-depth explanation and

review of stigma was presented to strengthen my analysis. Stephen P. Hinshaw’s book

called “Mark of Shame: Stigma of Mental Illness and an Agenda for Change” provides

the strong description and analysis of mental illness stigma I needed. It talks about

mental illness stigma in context of history, theories from evolutionary psychology, social

psychology and sociology, empirical research and culture. Lastly, it also proposes

solutions to combat mental illness stigma. “It is simultaneously rigorous and

compassionate, scientific and humanistic, analytical and action-oriented”

(Global.oup.com). This book also helped me to not constrain the reason for mental

illness stigma as a function of culture alone. It helped me account for other factors that

affect mental illness stigma as well.

Research Data, Theory and Analysis

As suggested by Laungani and Abdullah & Brown’s research work, mental illness is

affected by stigma which varies across culture, therefore in order to understand mental

illness correctly and extensively it is important to study it as it varies across culture. As

Laungani points out, culture is a set of beliefs and practices about “right and wrong,

good and bad, proper and improper, healthy and unhealthy, normal and abnormal”. This

does not suggest that mental illness stigma should be viewed in terms of cultural

relativism. Cultural relativism, established by Franz Boaz anthropological research, is

the principle that suggests that human being’s beliefs, values and activities should be

understood as a function of their culture. Mental illness cannot be explained through

cultural relativism because that would suggest the mental illness in itself is cultural
specific. However, experiences felt in mental illness is not culturally specific at all, but

the “construction of an experience, its interpretation, and the meaning one assigns to

the experience” (Laungani P, 1989) is culturally specific.

Bearing this in mind, I head-started my research to understand mental illness stigma in

Pakistan. I have done this through conducting surveys and interviews from three set of

people: general Pakistani community, mental disordered individuals and psychiatrists

who are practicing in Pakistan and well-versed in the culture of Pakistani community.

General Pakistani Community

The broader research objective while carrying out this research was to establish

existence of stigma for mental disordered in Pakistan and to analyze the aspects of the

Pakistani culture that gives rise to this stigma. My sample size constituted of 93% of

people who fell in the age bracket of 18-23 and 80% of people who had at least

completed their Intermediate/A’levels while 11% had at least completed a Bachelor’s

degree. Around 80% of the people who I interviewed had encountered somebody with

mental illness. This justifies the extensive presence of mental illness in Pakistan and

calls for the need of research paper like these to delve deeper into the problem.

According to Abdullah and Brown, individuals with mental illness get restricted access to

opportunities and resources due to the discrimination they suffer. This limits the extent

to which they can participate in the society and behave in normative ways. Eventually it

makes them internalize the devaluation they face and seek social withdrawal and

secrecy. This social withdrawal in turn makes them lesser likely to get employed and

hence the stigma for their mental illness becomes a self-fulfilling prophecy. While they
were not much incompetent to get a job before, the degradation they face has made

them believe that they are actually incompetent to get employed. In my quest to find if

the mental disorderly can be economically active in Pakistan, I asked my interviewees if

they would employ somebody with mental illness if they were an employer. More people

replied in negative than in affirmative. When I inquired to justify their preferred course of

action, I received interesting replies. One justified his choice to not employ a mental

disordered individual by saying: “As a manager, I would not like the efficiency of my

company halted in anyway and I am afraid the kind of work I deal in is mostly not fit for

the mentally abnormal”. Another similar reply was: “I'll have to consider the company's

productivity”. The second category of responses, unsurprisingly, was related to their

seemingly potential dangerousness they might pose to the workplace. The third

category of replies was more broad minded and pleasing where people said that mental

disordered individuals should be given equal employment opportunities and that their

skills are more important than their mental disorderliness. One interviewee also

brilliantly pointed out that “Hospital is not the only place where we can treat

psychological/Mental problems.” However, these kind of responses were very

infrequent. Hence, it can be reasonably established through this that mental illness

stigma exists in Pakistan. But, what are the aspects of Pakistan culture that makes

employers not hire people with mental illness stigma? In the more popular languages

spoken in Pakistan, most terms for mental disorders do not have their proper Urdu

translation. Most of them translate into “pagal” which literally means madmen or crazy

and therefore has very negative connotations to it. This limits an average Pakistani’s

ability to think of a mental disordered individual over and above his disability.
The second kind of questions was concerned with finding out Pakistani community’s

willingness to socialize with somebody who has a mental disorder. I asked a series of

questions in order to find the prevailing inclination. Interestingly, most people illustrated

tolerance against socializing with mentally disordered individuals. However, their

responses were not very enthusiastic when they were asked if they would initiate

socializing with a mentally disordered individual.

The third kind of questions was concerned with finding out if professional help is

available and readily sought in Pakistan. I asked my interviewees this objective

question: “Do you tend to negatively judge a mentally disordered person who is seeking

professional help?” and 94.5% of people answered with a “no”. However, when I asked:

“Do you think that victims of mental disorder feel hesitant to seek professional help in

Pakistan?” 98.15% of people replied with a “yes”. This dichotomy helps explains why

people in Pakistan do not consider mental disorder stigma a grave concern. As I will

explain in more detail later, Pakistani community lacks the education and awareness to

recognize mental disorder stigma.

Mentally Disordered Individuals

I met with a Pakistani mentally disordered patient Hamood Jaffery who suffers from

epilepsy. He thanked me for my interest in this area of research and mentioned that his

condition has caused him to lose many of his friends. He does not like when his friends

feel sorry for him and treat him differently. He has also observed that his friends find it
hard to trust him and consider him reliable because of his condition. He used to get very

bad grades in his primary school because his condition required him to get absent a lot

and he also had to take a gap year because he could not get admission into any

university. Due to this, he feels that his parents and extended family

doesn’t like him. Abdullah and Brown’s research work explains that in Asian culture

occupational and academic success is considered worthy of recognition and since

mentally disordered individuals find it hard to achieve it, they are stigmatized like in

Hamood’s case. Since mental disordered individuals are unlikely to look after their

parents when they’re old and sick, so their family is also stigmatized.

Psychiatrists

The general community and the mentally disordered individuals could not give as

objective, unbiased, informed and practical view about mental disorder stigma as the

psychiatrists who have studied and deal with them on a daily basis can. I conversed

with Dr Nighat Fatima who did her Diploma in Psychiatry from Civil Hospital, Karachi in

addition to MBBS from Dow Medical College Karachi.

When I asked her if employers are deterred to hire someone with mental illness, she

replied affirmatively. She thinks that in our society, people who divert away from norms

are discarded. Pittu Laungani also analyzed this as a reason for mental illness stigma.

According to her, Indian society like Pakistani society is a majorly collectivist society.

For an individual to be considered a part of the community, it is important that he abides

by the norms of the larger community. Women, are expected to abide by these norms
more than men, therefore in Pakistani culture mental illness stigma is found more

towards women than man.

Dr Nighat Fatima attributes lack of education and awareness to be a key reason for the

mental disorder stigma. People are not aware that mental disorders are mostly curable

and mental disordered individuals can function as well as everyone else in most areas.

Conclusion

I have deduced from my research findings that mental illness stigma does exist in

Pakistan and the reason for it are lack of education, the community’s tendency to regard

academic and occupational success in high regard, collectivism and women

disempowerment. However, these reasons are not exhaustive and more research is

required in this area to find about mental illness stigma in Pakistan and overcome it.

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http://keh.org.pk/

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